Teaching Chewing: A Structured Approach

Laisa Marie Gregorio, UST OT Intern, 2013

BackgroundBackground

Chewing is one of many problems commonly seen in children with congenital delays, e.g. Down syndrome, autism spectrum disorder, cri du chat and cerebral palsy.

Problems in chewing = neuromotor deficits and or lack of experience

BackgroundBackground Institutional deprivation = lack of exposure to

or practice in chewing high textured food

Lack of literature (Butterfield & Parson, 1973) Modeling, shaping and

positive reinforcement = teaching a kid with DS to bite graham crackers

(Gisel et. al., 1994) oral-motor intervention for kids with CP; includes 3 components (tongue lateralization, lip control and vigor of chewing); cookie progresses in hardness; 5-7 min before school lunch meal for 10-20 weeks

BackgroundBackground

Oral-motor functioning and behavioral approaches Stimulus fading Positive/social reinforcement Peer modeling Token reinforcement

= Goal of the study

MethodMethod

Participant and Setting9 y/o Sam with Down syndrome Eats only limited number of pureed foods Leaves meal before finishing Refuses to self-feed Goal: to establish chewing, increase variety and

texture of solid foods eaten, establish open-cup drinking, eliminate inappropriate mealtime behaviors

124 meal sessions, 19 days, day-treatment program

MethodMethod

Participant and Setting5 y/o Frank who has had kidney transplant,

stroke, microcephaly, and neuromotor dysfunction

Gastrostomy tube dependent Only eats smooth foods Drinks thin liquids without difficulty

MethodMethod

Participant and Setting Left side weakness, difficulty coordinating

tongue movement Goal: to establish chewing, increase texture

of solid foods eaten, eliminate inappropriate mealtime behaviors, eliminate gastrostomy feedings

149 meal sessions, 20 days, day-treatment feeding program

MethodMethod

Sessions were conducted by a PhD- or master’s-level feeding therapist

Some by graduate interns under supervision of a feeding therapist

Neither child required adaptive seating

Final 2 weeks: different environments by different persons to promote generalization

Dependent MeasuresDependent Measures

Data by therapist in charge

Interobserver reliability: another therapist or a graduate intern

Primary behaviors:

Chew: at least 3x within 5 s

Mouth clean: within 30 s of acceptance

Used as determinants of the outcomes of the intervention

Dependent MeasuresDependent MeasuresSecondary Behaviors:

Accept: within 5 s of presentation

Expel: before next bite

Negative vocalizations

Gag: neck extension, tongue protrusion, changes in skin color

Tongue lateralization

Bite

Dependent MeasuresDependent Measures

Dietary intake by pediatric nutritionist

Interobserver agreement:

Sam: reliability of 30% of chewing sessions – chew and mouth clean

82% agreement (7 – 100%)

reliability of 39% of texture-fading sessions and mouth clean

87% agreement (23 – 100%)

Dependent MeasuresDependent Measures

Interobserver agreement:

Frank: reliability of 24% of chewing sessions – chew and mouth clean

88% agreement (13 – 100%)

reliability of 30% of texture-fading sessions and mouth clean

92% agreement (75 – 100%)

Procedures - Procedures - BaselineBaseline

Conducted to assess children’s ability to eat high-textured foods and to chew

Baseline chewing sessions 10 min Child was presented with dry, crisp foods,

and asked to take bites All inappropriate meal behaviors are ignored Attempt to leave -> redirected

Procedures - Procedures - BaselineBaseline

Baseline texture-fading sessions Presented with regular-textured table

foods and milk from an open cup Same as chewing sessions

Procedures - Procedures - BaselineBaseline

Treatment package Instruct the child to bite and chew Improve tongue lateralization Improve lip closure Increase texture of foods eaten

Implemented in 2 types of meal sessions

Procedures – Procedures – Chewing Chewing SessionsSessions

Primary focus: biting and chewing 10 min Bite a small piece of crisp, dissolvable food

on molars Bites = reinforcement Preferred drink after each bite Chews = additional praise Expels = placed back

Procedures – Procedures – Chewing Chewing SessionsSessions

Primary focus: biting and chewing Swallows w/o biting = another piece placed

on molars Refuses = held to mouth w/o comment until

accepted Gagging ignored Alternate placing of food to L or R Ended when timer rang

Procedures – Procedures – Decision Decision RulesRules

Used to change the schedule of reinforcement

Size of the food pieces presented also increased

Sam: termination criterion was changed from 10 min to specific number of bites (9)

Procedures – Procedures – Texture-Texture-fading Sessionsfading Sessions

Primary focus: increase tolerance of higher-textured foods, improve lip closure, improve tongue lateralization 20 min Bite textured food Bites = praise, given verbal prompts Chewing or attempting to chew = praised +

tangible reinforcement for 10 s Expels = ignored, placed back Refuses = held to mouth w/o comment until

accepted

Procedures – Procedures – Texture-Texture-fading Sessionsfading Sessions

Primary focus: increase tolerance of higher-textured foods, improve lip closure, improve tongue lateralization Gagging ignored Alternate placing of food to L or R Tongue lateralization = praise + tangible

reinforcement for 10 s Consumes preferred liquid = praise + tangible

reinforcement for 10 s Ended when timer rang

Procedures – Procedures – Decision Decision RulesRules

Used to determine when texture would be increased to the next step in the fading sequenceMouth clean ≥ 80% of bites, 3/4

mealsExpels ≤ 20% of bites, 3/4 mealsGags ≤ 20% of bites, 3/4 meals

Procedures – Procedures – Food Food texturestextures

Food textures Pureed – smooth food w/o lumps Ground – processed food (lumps w/

size no larger than 0.25 in) Mashed – with a fork (lumps’ size

within 0.25 - 0.5 in) Table – regular-texture table food

Procedures – Procedures – Food Food texturestextures

Table – regular-texture table food If fading procedure required less than

spoonful, table food was cut into smaller pieces (approx. 0.5 in)

At the end of treatment, both boys were biting pieces off some foods

Starting texture – ground Texture-fading manipulated 2 variables:

texture and spoon volume

Procedures – Procedures – MealsMeals

At the end of treatment for both children

Presented with a range of table foods Praises were given for accepting and

chewing bites of food Conducted at a variety of settings

with children’s caregivers to promote generalization

Parent TrainingParent Training Done before discharge from intensive

treatment Therapists as models, then return

demonstration by caregivers for feedback

Simplified version of data collection system

Training videos and written home treatment plan

Experimental DesignExperimental Design

Multiple baseline design was used to evaluate effectiveness of treatment

3 baseline chewing sessions and 3 baseline texture-fading sessions for Sam

5 baseline chewing sessions and 5 baseline texture-fading sessions for Frank

ResultsResults

Effective in increasing both variety and texture of food eaten by both boys

Successful in eliminating the need for Frank’s gastrostomy tube feedings

ResultsResults

Sam 13 – more

than 80 foods

Frank 3 low

textured-foods – 50 foods

ResultsResults

ResultsResults

DiscussionDiscussion Intervention was able to achieve its goals

Both boys were able to eat family meals and to eat in a variety of settings outside home

Not clear which component was responsible for the results

Not all of the skills targeted might be necessary for some kids Component analysis

DiscussionDiscussion Treatment differs from others with the

same goals but through the use of chewy tubes or other nonnutritive objects

Thus, study agrees with Gisel: use of food stimuli in treatment would elicit natural eating reaction Also prevents possible problems in

generalization

RecommendationRecommendation

Study was conducted in an intensive basis under tightly controlled environment of a day-treatment program -> other settings with other samples of children

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